Encouraging appropriate gestational weight gain in high-risk gravida: A randomized controlled trial.

Trial Design: Excessive gestational weight gain (GWG) can increase pregnancy morbidity and is particularly problematic for women with pregestational obesity. A lifestyle modification intervention was introduced to gravida with obesity to decrease excessive GWG as compared to usual care (UC). Methods: A randomized controlled trial was conducted to improve healthy lifestyle behaviors to manage appropriate GWG. Consenting participants with prepregnancy obesity and singletons ≤17 weeks were randomized to (1) Usual Care (UC): usual written educational materials and counseling by obstetric provider or (2) Enhanced Care (EC): UC plus (a) personalized letter from physician detailing appropriate GWG; (b) access to individualized GWG chart; (c) ongoing counseling with registered dietitian/nutritionist (RDN). The primary outcome was proportion with GWG ≤9.1 kg, as this is upper limit recommended by Institute of Medicine (IOM). Total GWG and GWG as less than/within/greater than IOM recommendations (in aggregate and stratified by obesity class), and pregnancy/neonatal outcomes were evaluated as secondary outcomes. Results: Analyses included 105 participants in EC and 109 in UC arms. The groups had similar demographics: 46% with class I obesity, 26% class II, and 28% class III. There were no group differences for any GWG, pregnancy, or neonatal outcomes when analyzed in aggregate. As compared to those randomized to the EC arm, participants in UC arm with class I obesity gained 1.4 kg less and those with class II obesity were significantly more likely to gain within IOM guidelines (14.8% vs. 40.0%, adjusted p = 0.04). Participants with class III obesity randomized to EC arm were more likely to gain within IOM guidelines as compared to participants randomized to UC arm (29.0% vs. 6.7%, adjusted p = 0.02). Conclusion: There were no differences in GWG observed between groups when analyzing participants in aggregate. However, a physician's letter detailing appropriate GWG, patient portal access to a personalized GWG chart, and RDN consultation were helpful for encouraging GWG within IOM guidelines for women with prepregnancy class III obesity. Women with class I or II obesity had better GWG outcomes without these additional interventions.

Measuring compliance with a maternal fetal medicine obesity protocol: a secondary analysis.

BACKGROUND: Current trends in patient safety include protocolization of care with assumed compliance to the protocol by health care providers. In 2016, Schuster et al. found that implementation of a protocol for management of obese pregnant patients that included delivery by estimated due date (EDD) actually resulted in a decrease in cesarean deliveries. Although compliance to the aspect of the protocol that affected the primary outcome of that study was evaluated, compliance to every aspect of the protocol was not analyzed. Recent studies have suggested improvements in protocol outcomes when compliance is measured. Therefore, we sought to evaluate compliance to the other aspects of the Geisinger Maternal Fetal Medicine obesity protocol (MOP). OBJECTIVE: The objective of this study was to identify compliance with all elements of the Geisinger MOP and identify areas for potential improvement with regards to compliance. STUDY DESIGN: We performed a secondary analysis of the original study to evaluate compliance with protocol aspects during the study period. Ninety-seven patients were randomly selected for chart review. We assessed compliance with each element of the protocol, including early diabetes screening, fetal monitoring, growth ultrasounds, and delivery by EDD using simple statistics. RESULTS: By obesity class, compliance was as follows: for class I obese patients, compliance with early diabetes screening was 30% (12/36 patients). For class II obese patients, compliance with early diabetes screening was 57.1% (12/21 patients), and compliance with serial growth ultrasounds was 85.7% (18/21 patients). For class III obese patients, compliance with early diabetes screening was 74.4% (29/39 patients), compliance with serial growth ultrasounds was 84.6% (33/39 patients), compliance with nonstress tests was 82.0% (32/39 patients). Compliance with the recommendation for delivery by estimated due date was 95% (37/39 class III obese patients). CONCLUSION: Although compliance was excellent with delivery by EDD, compliance with remaining recommendations was low. This suggests additional interventions are important to maintain compliance.

Labor induction in the patient with preterm premature rupture of membranes.

Preterm premature rupture of membranes (PPROM) affects up to one-third of all preterm births and confers serious maternal risks, including intra-amniotic infection, and an increased risk of neonatal complications, including respiratory distress and intraventricular hemorrhage. Management of PPROM is a highly individualized process that requires an accurate determination of gestational age and causal factors, as well as the balancing of maternal and fetal risks. In this review of the existing literature on induction of labor in PPROM, we examine the differences in appropriate management of patients with early (32 weeks 0 days to 33 weeks 6 days) and near term (34 weeks 0 days to 36 weeks 6 days) PPROM, and compare the safety and efficacy of available treatment options. This review of previous research findings provides general guidelines for clinical decision making and highlights the need for future research on management of PPROM.

Suture versus staples for skin closure after cesarean: a metaanalysis.

OBJECTIVE: We sought to perform a metaanalysis to synthesize randomized clinical trials of cesarean skin closure by subcuticular absorbable suture vs metal staples for the outcomes of wound complications, pain perception, patient satisfaction, cosmesis, and operating time. STUDY DESIGN: A systematic search was performed using MEDLINE, Cochrane Databases, and ClinicalTrials.gov registries. We included randomized trials comparing absorbable suture vs metal staples for cesarean skin closure. Data were abstracted regarding wound complications, patient pain perception, patient satisfaction, cosmesis as assessed by the physician and patient, and operating time. RESULTS: Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43), as there were no significant differences in infection, hematoma, seroma, or readmission. There were also no significant differences in pain perception, patient satisfaction, and cosmetic assessments between the groups. Operating time was approximately 7 minutes longer in those closed with suture (95% CI, 3.10-11.31). CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.